after-action report/improvement plan template€¦ · web viewthe after-action report/improvement...

[Exercise Name]After-Action Report/Improvement Plan[Date]

The After-Action Report/Improvement Plan (AAR/IP) aligns exercise objectives with preparedness doctrine to include the National Preparedness Goal and related frameworks and guidance. Exercise information required for preparedness reporting and trend analysis is included; users are encouraged to add additional sections as needed to support their own organizational needs.

Rev. April 2013HSEEP-IP01

After-Action Report/ [Exercise Name]Improvement Plan (AAR/IP) [Exercise Name Continued]

EXERCISE OVERVIEW

Exercise Name [Insert the formal name of exercise, which should match the name in the document header]

Exercise Dates [Indicate the start and end dates of the exercise]

ScopeThis exercise is a [exercise type], planned for [exercise duration] at [exercise location]. Exercise play is limited to [exercise parameters].

Mission Area(s) [Prevention, Protection, Mitigation, Response, and/or Recovery]

Core CapabilitiesEmergency Operations Coordination, Information-Sharing, Medical Surge, Healthcare System Preparedness, Healthcare System Recovery

Add other capabilities, as appropriate to your exercise

Objectives 1. Demonstrate the ability of the hospital to notify staff and operate its Hospital Command Center (HCC). Include activation of Hospital Incident Command System (HICS).

2. Demonstrate the ability of the hospital to implement information-sharing processes on a regular basis with other mutual aid partners, the Regional DOH Office, and with appropriate government agencies, utilizing redundant interoperable communications to:

a) maintain situational awareness3. Demonstrate the ability of the hospital to communicate consistent

elements of information (EEIs) to the Regional DOH Office, other mutual aid partners and the local public health/medical lead (PERFORMANCE MEASURE).

4. Demonstrate the ability of the hospital to inventory patient census, acuity, and staffed bed availability in real time, and again after rapid patient discharge in order to decompress the facility (offload patients) GOAL: 2 hours

5. Demonstrate the hospital’s coordination of hospital surge operations (on-load patients) with EMS operations.

6. Evaluate the ability of the hospital to move and track patients to their final disposition (ED to a staffed available bed; hospital to healthcare facility: If an evacuation scenario - must use eFINDS).

7. Demonstrate inclusion of individuals (highly suggested = minimum of 3) from one or more of the following at-risk populations :

Frail Elderly Pediatrics

Exercise Overview 1 [Sponsor Organization]FOR OFFICIAL USE ONLY

Homeland Security Exercise and Evaluation Program (HSEEP)


Physically disabled Hearing impaired/deaf Blind Behaviorally involved Pregnant women Non-English speaking Access/functional needs

8. Evaluate the hospital’s ability to reference and incorporate components of its appropriate plans (e.g., COOP, 96 hour Sustainability Plan, the Isolation and Quarantine Plan, the Alternate Care Site Plan, etc.) to prioritize and continue mission essential services after HCC activation.

9. Determine if event has caused a complete or partial disruption of health care service delivery, and delineate how this disruption occurred with prioritized mission essential functions (suggested minimum of 3).

10. Demonstrate appropriate activities that focus on rapid resumption of the prioritized mission essential functions (suggested minimum of 3).

Add additional, as appropriate to your exercise

Threat or Hazard [List the threat or hazard (e.g. natural/hurricane, technological/radiological release)]

Scenario [Insert a brief overview of the exercise scenario, including scenario impacts (2-3 sentences)]

Sponsor [Insert the name of the sponsor organization, as well as any grant programs being utilized, if applicable]

Participating Organizations

[Insert a brief summary of the total number of participants and participation level (i.e., Federal, State, local, Tribal, non-governmental organizations (NGOs), and/or international agencies). Consider including the full list of participating agencies in Appendix B. Delete Appendix B if not required.]

Point of Contact [Insert the name, title, agency, address, phone number, and email address of the primary exercise POC (e.g., exercise director or exercise sponsor)]

Exercise Overview 2 [Sponsor Organization]FOR OFFICIAL USE ONLY

Homeland Security Exercise and Evaluation Program (HSEEP)


ANALYSIS OF CORE CAPABILITIESAligning exercise objectives and core capabilities provides a consistent taxonomy for evaluation that transcends individual exercises to support preparedness reporting and trend analysis. Table 1 includes the exercise objectives, aligned core capabilities, and performance ratings for each core capability as observed during the exercise and determined by the evaluation team.

Objective Core Capability

Performed without

Challenges (P)

Performed with Some Challenges

(S)

Performed with Major Challenges

(M)

Unable to be

Performed (U)

Demonstrate the ability of the hospital to notify staff and operate its Hospital Command Center (HCC). Include activation of Hospital Incident Command System (HICS).

Emergency Operations

Coordination

Demonstrate the ability of the hospital to implement information-sharing processes on a regular basis with other mutual aid partners, the Regional DOH Office, and with appropriate government agencies, utilizing redundant interoperable communications to:

maintain situational awareness

Demonstrate the ability of the hospital to communicate consistent elements of information (EEIs) to the Regional DOH Office, other mutual aid partners and the local public health/medical lead (PERFORMANCE MEASURE).

Information Sharing

Demonstrate the ability of the hospital to inventory patient

Medical Surge

Appendix A: Improvement Plan3 [Sponsor Organization]

FOR OFFICIAL USE ONLYHomeland Security Exercise and Evaluation Program (HSEEP)



Performed without

Challenges (P)


(S)


(M)

Unable to be

Performed (U)

census, acuity, and staffed bed availability in real time, and again after rapid patient discharge in order to decompress the facility (offload patients) GOAL: 2 hours

Demonstrate the hospital’s coordination of hospital surge operations (on-load patients) with EMS operations.

Medical Surge

Evaluate the ability of the hospital to move and track patients to their final disposition (ED to a staffed available bed; hospital to healthcare facility: If an evacuation scenario - must use eFINDS)

Medical Surge

Demonstrate inclusion of individuals (highly suggested = minimum of 3) from one or more of the following at-risk populations:

Frail Elderly Pediatrics Physically disabled Hearing impaired/deaf Blind Behaviorally involved Pregnant women Non-English speaking Access/functional

needs

Medical Surge

Evaluate the hospital’s ability to reference and incorporate components of its appropriate plans

Healthcare System

Preparedness





Performed without

Challenges (P)


(S)


(M)

Unable to be

Performed (U)

(e.g., COOP, 96 hour Sustainability Plan, the Isolation and Quarantine Plan, the Alternate Care Site Plan, etc.) to prioritize and continue mission essential services after HCC activation.

Determine if event has caused a complete or partial disruption of health care service delivery, and delineate how this disruption occurred with prioritized mission essential functions (suggested minimum of 3).

Healthcare System

Preparedness

Demonstrate appropriate activities that focus on rapid resumption of the prioritized mission essential functions (suggested minimum of 3).

Healthcare System

Recovery

Ratings Definitions: Performed without Challenges (P): The targets and critical tasks associated with the core capability were

completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws.

Performed with Some Challenges (S): The targets and critical tasks associated with the core capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. However, opportunities to enhance effectiveness and/or efficiency were identified.

Performed with Major Challenges (M): The targets and critical tasks associated with the core capability were completed in a manner that achieved the objective(s), but some or all of the following were observed: demonstrated performance had a negative impact on the performance of other activities; contributed to additional health and/or safety risks for the public or for emergency workers; and/or was not conducted in accordance with applicable plans, policies, procedures, regulations, and laws.

Unable to be Performed (U): The targets and critical tasks associated with the core capability were not performed in a manner that achieved the objective(s).




Table 1. Summary of Core Capability Performance

The following sections provide an overview of the performance related to each exercise objective and associated core capability, highlighting strengths and areas for improvement.



After-Action Report/Improvement Plan (AAR/IP) [Exercise Name Continued]

The strengths and areas for improvement for each core capability aligned to this objective are described in this section.

Core Capability 1

Emergency Operations CoordinationEmergency Operations Coordination regarding healthcare is the ability for healthcare organizations to engage with incident management at the Emergency Operations Center or with on-scene incident management during an incident to coordinate information and resource allocation for affected healthcare organizations. This is done through multi-agency coordination representing healthcare organizations or by integrating this coordination into plans and protocols that guide incident management to make the appropriate decisions. Coordination ensures that the healthcare organizations, incident management, and the public have relevant and timely information about the status and needs of the healthcare delivery system in the community. This enables healthcare organizations to coordinate their response with that of the community response and according to the framework of the National Incident Management System (NIMS).

Objective 1: Demonstrate the ability of the hospital to notify staff and operate its Hospital Command Center (HCC). Include activation of Hospital Incident Command System (HICS).

Strengths

The [full or partial] capability level can be attributed to the following strengths:

Strength 1: [Observation statement]



Add as many Strengths as identified in your exercise

Areas for Improvement

The following areas require improvement to achieve the full capability level:

Area for Improvement 1: [Observation statement. This should clearly state the problem or gap; it should not include a recommendation or corrective action, as those will be documented in the Improvement Plan.]

Reference: [List any relevant plans, policies, procedures, regulations, or laws.]

Analysis: [Provide a root cause analysis or summary of why the full capability level was not achieved.]

Appendix B: Exercise Participants B-1 [Sponsor Organization]



Area for Improvement 2: [Observation statement]



Add as many Areas for Improvement as needed, using this format.

______________________________________________________________________________


Core Capability 2

Information Sharing Information sharing is the ability to conduct multijurisdictional, multidisciplinary exchange of public health and medical related information and situational awareness between the healthcare system and local, state, Federal, tribal and territorial levels of government and the private sector. This includes the sharing of healthcare information through routine coordination with the Joint Information System for dissemination to the local, state and Federal levels of government and the community in preparation for and response to events or incidents of public health and medical significance.

Objective 2: Demonstrate the ability of the hospital to implement information-sharing processes on a regular basis with other mutual aid partners, the Regional DOH Office, and with appropriate government agencies, utilizing redundant interoperable communications to:

a) maintain situational awareness

Strengths


















______________________________________________________________________________


Core Capability 2

Information Sharing

Information sharing is the ability to conduct multijurisdictional, multidisciplinary exchange of public health and medical related information and situational awareness between the healthcare system and local, state, Federal, tribal and territorial levels of government and the private sector. This includes the sharing of healthcare information through routine coordination with the Joint Information System for dissemination to the local, state and Federal levels of government and the community in preparation for and response to events or incidents of public health and medical significance.

Objective 3: Demonstrate the ability of the hospital to communicate consistent elements of information (EEIs) to the Regional DOH Office, other mutual aid partners and the local public health/medical lead (PERFORMANCE MEASURE).

Strengths


















______________________________________________________________________________


Core Capability 3

Medical Surge

The Medical Surge capability is the ability to provide adequate medical evaluations and care during incidents that exceed the limits of the normal medical infrastructure within the community. This encompasses the ability of healthcare organizations to survive an all-hazards incident, and maintain or rapidly recover operations that were compromised.

Objective 4: Demonstrate the ability of the hospital to inventory patient census, acuity, and staffed bed availability in real time, and again after rapid patient discharge in order to decompress the facility (offload patients). GOAL: 2 hours

Strengths


















______________________________________________________________________________


Core Capability 3

Medical Surge


Objective 5: Demonstrate the hospital’s coordination of hospital surge operations (on-load patients) with EMS operations.




Strengths















______________________________________________________________________________


Core Capability 3

Medical Surge

The Medical Surge capability is the ability to provide adequate medical evaluations and care during incidents that exceed the limits of the normal medical infrastructure within the




community. This encompasses the ability of healthcare organizations to survive an all-hazards incident, and maintain or rapidly recover operations that were compromised.

Objective 6: Evaluate the ability of the hospital to move and track patients to their final disposition (ED to a staffed available bed; hospital to healthcare facility: If an evacuation scenario - must use eFINDS).

Strengths















______________________________________________________________________________





Core Capability 3

Medical Surge


Objective 7: Demonstrate inclusion of individuals (highly suggested = minimum of 3) from one or more of the following at-risk populations:

Frail Elderly Pediatrics Physically disabled Hearing impaired/deaf Blind Behaviorally involved Pregnant women Non-English speaking Access/functional needs

Strengths











Area for Improvement 2: [Observation statement]Appendix B: Exercise Participants B-8 [Sponsor Organization]






______________________________________________________________________________


Core Capabilities 4 and 5

Healthcare System Preparedness and Healthcare System Recovery

Healthcare System Preparedness is the ability of a community's healthcare system to prepare to, respond, and recover from incidents that have a public health and medical impact in the short and long term. The healthcare system role in community preparedness involves coordination with emergency management, public health, mental/behavioral health providers, community and faith-based partners, state, local, and territorial governments to do the following:

Provide and sustain a tiered, scalable, and flexible approach to attain needed disaster response and recovery capabilities while not jeopardizing services to individuals in the community

Provide timely monitoring and management of resources Coordinate the allocation of emergency medical care resources Provide timely and relevant information on the status of the incident and healthcare

system to key stakeholders Healthcare system preparedness is achieved through a continuous cycle of planning, organizing and equipping, training, exercises, evaluations and corrective actions.

Healthcare System Recovery involves the collaboration with Emergency Management and other community partners, (e.g., public health, business, and education) to develop efficient processes and advocate for the rebuilding of public health, medical, and mental/behavioral health systems to at least a level of functioning comparable to pre-incident levels and improved levels where possible. The focus is an effective and efficient return to normalcy or a new standard of normalcy for the provision of healthcare delivery to the community.

Objective 8: Evaluate the hospital’s ability to reference and incorporate components of its appropriate plans (e.g., COOP, 96 hour Sustainability Plan, the Isolation and Quarantine Plan, the Alternate Care Site Plan, etc.) to prioritize and continue mission essential services after HCC activation.




Strengths















___________________________________________________________________




Healthcare System Preparedness is the ability of a community's healthcare system to prepare to, respond, and recover from incidents that have a public health and medical impact in the short




and long term. The healthcare system role in community preparedness involves coordination with emergency management, public health, mental/behavioral health providers, community and faith-based partners, state, local, and territorial governments to do the following:





Objective 9: Determine if event has caused a complete or partial disruption of health care service delivery, and delineate how this disruption occurred with prioritized mission essential functions (suggested minimum of 3).

Strengths


















___________________________________________________________________




Healthcare System Preparedness is the ability of a community's healthcare system to prepare to, respond, and recover from incidents that have a public health and medical impact in the short and long term. The healthcare system role in community preparedness involves coordination with emergency management, public health, mental/behavioral health providers, community and faith-based partners, state, local, and territorial governments to do the following:





Objective 10: Demonstrate appropriate activities that focus on rapid resumption of the prioritized mission essential functions (suggested minimum of 3).




Strengths


















PLEASE COMPLETE EACH COLUMN FOR EACH AREA FOR IMPROVEMENT IDENTIFIED

APPENDIX A: IMPROVEMENT PLANThis IP has been developed specifically for [Organization or Jurisdiction] as a result of [Exercise Name] conducted on [date of exercise].

Core Capability

Issue/Area for

Improvement

Corrective Action

Capability Element1

Primary Responsible

Organization

Organization POC

Start Date

Completion Date

______________________________________________ Capability Elements are: Planning, Organization, Equipment, Training, Exercise, Policy, or Personnel.




Please list all participating organizations/populations

APPENDIX B: EXERCISE PARTICIPANTSParticipating Organizations

Federal

State

Local Health Departments

Emergency Management

Emergency Medical Services

Vulnerable Populations Included

Representatives of At-risk/Vulnerable Populations on Design Team



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